Provider Demographics
NPI:1356051114
Name:DAVIS, CORY (PRS)
Entity type:Individual
Prefix:
First Name:CORY
Middle Name:
Last Name:DAVIS
Suffix:
Gender:M
Credentials:PRS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:456 HUNTER AVE
Mailing Address - Street 2:
Mailing Address - City:DAYTON
Mailing Address - State:OH
Mailing Address - Zip Code:45404-1564
Mailing Address - Country:US
Mailing Address - Phone:850-467-1290
Mailing Address - Fax:
Practice Address - Street 1:456 HUNTER AVE
Practice Address - Street 2:
Practice Address - City:DAYTON
Practice Address - State:OH
Practice Address - Zip Code:45404-1564
Practice Address - Country:US
Practice Address - Phone:850-467-1290
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2022-12-01
Last Update Date:2022-12-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OHAPS.003598175T00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes175T00000XOther Service ProvidersPeer Specialist